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A 75-year-old postmastectomy patient had a history of congestive heart failure. When her condition began to worsen, her doctor ordered 40 mg of furosemide (frusemide, Lasix) stat. Her nurse had another patient receiving 40 mg of Lasix, so she borrowed a dose and gave it to the postmastectomy patient. Later, the nurse transcribed the order and sent it to the pharmacy. The pharmacist immediately telephoned the unit and told the nurse to withhold the Lasix because the patient was allergic to the drug.
In her haste, the nurse hadn't checked the patient's medication administration record or chart. After the call from the pharmacist, she went back to the patient's room and discovered that the patient had already developed a rash on her trunk and face. The nurse called the doctor and got an order for diphenhydramine (Benadryl) to counteract the patient's adverse reaction.
Unless a true emergency exists, don't let a doctor's request for stat medication interfere with your responsibility to check your patient's records for allergies or other contraindications. If you borrow a dose from another patient's supply or from stock on the nursing unit, you're bypassing the safety net that the hospital has set up to prevent errors like this one-the nurse-pharmacist double-check..